The Impact of the Covid-19 Pandemic on Noncommunicable Disease Resources and Services

THE IMPACT OF THE COVID-19 PANDEMIC ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES:

RESULTS OF A RAPID ASSESSMENT

THE IMPACT OF THE COVID-19 PANDEMIC ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES:

RESULTS OF A RAPID ASSESSMENT The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment ISBN 978-92-4-001029-1 (electronic version) ISBN 978-92-4-001030-7 (print version)

© World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for n on-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. CONTENTS

ACKNOWLEDGEMENTS...... IV

LIST OF ACRONYMS...... V

INTRODUCTION...... 1

METHODS...... 1

RESULTS...... 2

INFRASTRUCTURE...... 2

POLICIES AND PLANS...... 4

NCD-RELATED HEALTH SERVICES...... 6

SURVEILLANCE...... 10

SUGGESTIONS FOR TECHNICAL SUPPORT...... 11

DISCUSSION...... 11

CONCLUSION...... 13

REFERENCES...... 13

ANNEXES...... 14

ANNEX 1: WHO MEMBER STATES AND SURVEY RESPONDENTS...... 15

ANNEX 2: LIST OF COUNTRIES BY WORLD BANK INCOME GROUP.....17

ANNEX 3: QUESTIONNAIRE...... 19

THE IMPACT OF THE COVID-19 PANDEMIC III ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT ACKNOWLEDGEMENTS

The survey was implemented by the Surveillance, Regional Office for Europe; Heba Fouad for the WHO Office Monitoring and Reporting Unit within the Department for the Eastern Mediterranean; Naveen Agarwal and Manju of Noncommunicable Diseases (NCDs), World Health Rani for the WHO Regional Office for South-East Asia; Organization, Geneva. Leanne Riley coordinated the overall and Hai-Rim Shin, Wendy Snowdon, Josaia Tiko and Nola implementation of the survey; Lubna Bhatti, Marie Clem Vanualailai for the WHO Regional Office for the Western Carlos, Arlene Quiambao and Patricia Rarau assisted with the Pacific. Additional thanks to staff in numerous WHO country questionnaire design and review; Stefan Savin constructed the offices who provided invaluable support in survey-related web-based questionnaire; Melanie Cowan performed all data communication with Member States. management and statistical analysis and lead the preparation of the final report. Colleagues from WHO headquarters also provided helpful input and support in the development of the survey questionnaire We wish to thank the NCD focal points in the WHO or reviewed the report: Alarcos Cieza, Elena Fidarova, regional offices for their generous support and assistance Aida Kaffel Rodriguez, Kaloyan Kamenov, Coraline Martin, in coordinating the survey with their respective Member Bente Mikkelsen, Baridalyne Nongkynrih, Menno Van Hilten, States: Jean-Marie Dangou for the WHO Regional Office for Benoit Varenne, Cherian Varghese and Temo Waqanivalu. Africa; Roberta Caixeta, Carolina Chavez-Cortez and Dolores Ondarsuhu for the WHO Regional Office for the Americas; Finally, we thank all Member States that took part in the survey, Nino Berdzuli, Natalia Fedkina and Ivo Ravokac for the WHO allowing for the assessment and completion of this report.

IV LIST OF ACRONYMS

AFR WHO African Region

AMR WHO Region of the Americas

EMR WHO Eastern Mediterranean Region

EUR WHO European Region

NCD Noncommunicable disease

NCD CCS Noncommunicable disease country capacity survey

PPE Personal Protective Equipment

SEAR WHO South-East Asia Region

WHO World Health Organization

WPR WHO Western Pacific Region

THE IMPACT OF THE COVID-19 PANDEMIC V ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT THE IMPACT OF THE COVID-19 PANDEMIC ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES:

RESULTS OF A RAPID ASSESSMENT

VI INTRODUCTION

Noncommunicable diseases (NCDs), notably cardiovascular The disruption of health services is particularly problematic diseases, cancers, diabetes and chronic respiratory diseases, for those living with NCDs who need regular care. Several are the leading causes of death and disability globally, affecting examples from countries show how the disruption of NCD more people each year than all other causes combined. NCDs services has directly affected people. For example, screening, are responsible for over 70% of all deaths, with nearly 80% of case identification, and referral systems for cancer have all these deaths occurring in low- and middle-income countries (1). been affected by the COVID-19 pandemic which has resulted In addition, NCDs constitute approximately 80% of all years in a substantial decrease in cancer diagnoses (6). The reduction lived with disability globally (2). With the population ageing, in admission to hospital of patients with acute coronary rise in multimorbidity, longer life expectancies and increasing syndrome often results in increases in out-of-hospital deaths survival rates, more and more people are expected to live with and long-term complications of myocardial infarction (7). the health burden of NCDs (3,4). Disruption in rehabilitation services for people with NCDs

Due to their chronic and sometimes life-long nature, NCDs in various countries has potentially impacted their functional often require repeated interactions with the health system outcomes and consequently increased the burden of care (8). over long periods of time. This includes disease management These few examples, however, do not capture the whole involving access to essential medicines or rehabilitation picture around the world. There has not been comprehensive services. Not receiving the care needed often has devastating information gathered about the countries in which disruption consequences for persons living with NCDs. The unmet burden of NCD related services has occurred nor the extent of those of NCDs can lead to both health and economic consequences disruptions and the factors associated to those disruptions at global, country, household and individual levels, resulting in (such as inclusion in COVID-19 Strategic Plans). That severe disability, premature deaths, and billions of dollars in information is important to a) understand how countries economic loss each year (5). need to be supported during the response to COVID-19, b) With the rapid spread of COVID-19 across the world, plan how to build back better health systems with integrated the ability of countries to address and respond to NCDs has NCD services after the pandemic and c) shed light to the been impacted. The virus has caused broad disruptions to consequences of the disruptions in people’s lives. In line with health services while at the same time drawing attention this, the objective of this study was to gain direct in-depth to countries’ NCD burden, as those living with NCDs are knowledge from countries on the extent to which NCDs at increased risk of becoming severely ill with the virus. services have been affected during the COVID-19 response.

METHODS

Since 2001, WHO has been carrying out regular assessments within the ministry of health or national institute or agency of countries’ capacity to address and respond to the growing responsible for NCDs in each country. A link to a secure, burden of NCDs. Referred to as the NCD country capacity web-based questionnaire was shared with all focal points survey (NCD CCS), these assessments have been carried out by email on May 1, with the instructions to complete the seven times over the past two decades, with the most recent survey by May 15th. This deadline was ultimately extended round occurring in 2019. The survey serves not only as a to the 18th of May, though a handful of responses were means for WHO to assess country action on a wide range accepted after this date. Focal points also received a copy of of topics related to NCDs, but also as a guide for countries the questionnaire in MS Word and were informed they could on what actions to take at the national level in order to alternatively complete the questionnaire offline and submit strengthen their response to NCDs. their official response via email by returning the completed MS Word document. In order to obtain objective information on the impact of COVID-19 on NCDs both at the ministerial level as The questionnaire comprised 13 questions organized into well as in the health sector, WHO developed a follow-up the following five sections: Infrastructure, Policies and Plans, questionnaire to the regular NCD CCS. The questionnaire NCD-Related Health Services, Surveillance and Suggestions was completed by NCD focal points or designated colleagues [for technical guidance from WHO]. The complete

THE IMPACT OF THE COVID-19 PANDEMIC 1 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT questionnaire can be found in Annex 3. In the first two either by uploading it to the web-based platform, by sections, countries reported on the reallocation of funds and providing a web link, or sending via email. staffing from NCDs due to COVID-19, the inclusion of NCDs Information gathered was downloaded directly from the web- in the country’s COVID-19 response plan, the allocation of based platform to a Stata-readable file. Any offline responses additional funds for NCDs as part of the COVID-19 response received were entered into the online platform prior to and the postponement of NCD-related activities lead by downloading the complete dataset. Responses were aggregated the ministry of health. The third section included questions by WHO region, World Bank income group (2019 groupings – to assess the degree to which NCD-related services in see Annex 2), as well as COVID-19 transmission status as of the health sector had been impacted, the underlying causes the closing date of the survey (May 18th) (9). Countries with a of the disruptions and what means were being used to “pending” transmission status were excluded from any analyses overcome the disruptions. The section on surveillance was where responses were aggregated by transmission status. intended to capture whether or not countries were collecting For the percentages reported in the following section, the total data on NCD-related comorbidities in COVID-19 patients. number of responding countries (overall or by subgroup) was In addition to responding to the questions, countries were used as the denominator, unless otherwise indicated. asked to provide their national COVID-19 response plans,

RESULTS

In total, 163 Member States (84%) responded to the survey. Pacific regions (Table 1). Twenty-nine countries opted to All regions except the European Region had a response rate submit their response offline. National COVID-19 plans or of 80% or higher, with nearly all countries responding in related documents were received from 48 countries. the Eastern Mediterranean, South-East Asia and Western

TABLE 1 Response rate by WHO region

Region Total numbers of countries Number of responding countries Response rate AFR 47 41 87% AMR 35 29 83% EMR 21 18 86% EUR 53 39 74% SEAR 11 10 91% WPR 27 26 96% TOTAL 194 163 84%

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

INFRASTRUCTURE

Nearly all countries (94%) reported that all or some ministry of Eastern Mediterranean regions. All other countries reporting health staff with responsibility for NCDs and their risk factors reassignment of staff thus only delegated part of their NCD were supporting the COVID-19 efforts either full time or along staff to work on COVID-19 full time (20% of countries) with routine NCD activities (Figure 1). Only 13% of countries or had some or all staff working part time on the COVID-19 reported that all NCD staff were working full time on COVID-19, response (61%). a situation that was more common in the South-East Asia and

2 FIGURE 1 Percentage of countries with ministry of health (or equivalent institutes) staff with responsibility for NCDs and their risk factors being reassigned/deployed to help with COVID-19 response, by WHO region. 45

% of countries 15

0 AFR AMR EMR EUR SEAR WPR Global

YES - All staff supporting YES - All staff partially YES - Some staff supporting COVID-19 efforts full time supporting COVID-19 efforts COVID-19 efforts full time along with routine NCD activities

YES - Some staff partially NO Don’t know supporting COVID-19 efforts along with routine NCD activities WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

Countries were also asked about whether or not government NCDs to non-NCD services, with just seven countries (4%) funding initially allocated for NCDs had been reassigned reporting a loss of more than 50% of funds (Figure 2). It is to non-NCD services due to COVID-19 response efforts. worth noting that nearly a third of the countries in the African Nearly a third (31%) of countries did not know the answer to Region responding “None or not yet” (eight out of 23) added a this question and roughly half (49%) reported that no funds comment in their response indicating that there is not normally had been reassigned to date. Thus, only 20% of countries a budget for NCDs so they have given this response because reported that government funds had been reallocated from there is nothing to be re-allocated.

FIGURE 2 Percentage of countries where government funds initially allocated for NCDs have been reassigned to non-NCD services due to COVID-19 response efforts, by WHO region. 70

% of countries 30

0 AFR AMR EMR EUR SEAR WPR Global

Percentage of funds reallocated: None or not yet 1-25% 26-50% 51-75% 76-100% Don’t know

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

THE IMPACT OF THE COVID-19 PANDEMIC 3 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT POLICIES AND PLANS

Two-thirds (66%) of countries reported that ensuring the in 44 of the 107 plans (41%). In terms of regional differences, continuity of NCD services was included in the list of essential countries in the Region of the Americas were least likely to health services in their national COVID-19 response plan include chronic respiratory disease services in their national (Figure 3). Low- and lower-middle-income countries were COVID-19 plans (70% of countries reporting the inclusion markedly less likely to include NCDs in their COVID-19 NCDs in their COVID-19 plans), and countries in the African response plans than upper-middle- and high-income countries. Region were most likely to include rehabilitation services in Of the 107 countries that have included NCDs in the list of their national COVID-19 plans (63%). Dental services were essential services in their national COVID-19 response plans, also more likely to be included by countries in the African over 90% reported including cardiovascular disease services, Region (63%) and the Eastern Mediterranean Region (67%). cancer services and diabetes services (Figure 4). Additionally, Finally, although tobacco cessation services were not widely the vast majority of these countries reported including included globally, they were far more likely to be included by services for chronic respiratory diseases (86%) and chronic countries in the Eastern Mediterranean and South-East Asia kidney disease (85%), while around half reported including regions (67% of countries reporting the inclusion of NCDs in dental services (53%) and rehabilitation services (50%). their COVID-19 plans in each region). Tobacco cessation services were only reported to be included

FIGURE 3 Percentage of countries that included ensuring the continuity of NCD services in the list of essential health services in their national COVID-19 response plan, by WHO region and World Bank income group.

100 90 80 70 60 50 % of countries 40 30 20 10 0 AFR AMR EMR EUR SEAR WPR ow- ower- Upper- High- Global income middle- middle- income income income

Yes No/Not Yet Don’t know

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

4 FIGURE 4 Percentage of countries* with NCDs included in the list of essential services in their national COVID-19 response plan that have included specific NCD services in the plan, by WHO region. NCD services included in list of essential health services of countrys COVID-19 response plan

100 90 80 70 60 50 40 30 20 10 0 AFR AMR EMR EUR SEAR WPR Global % of countries with COVID-19 plans incl NCDs Cardiovascular disease services Cancer services Diabetes services

Chronic respiratory disease services Chronic kidney disease and dialysis services Dental services

Rehabilitation services Tobacco cessation services Others

* Out of 107 countries reporting to have NCD service continuity in the list of essential services in their national COVID-19 response plan

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

Twenty-eight countries (17%) reported that there was group or region, with the one exception that countries in additional funding allocated for NCDs in the government the Western Pacific Region were far more likely to report that budget for the COVID-19 response, although a considerable additional funding had been allocated for NCDs (35% versus number of countries (40 or 25%) were unable to answer this 11-20% in all other regions). question (Figure 5). There was little variation across income

FIGURE 5 Percentage of countries with additional funding allocated for NCDs in the government budget for the COVID-19 response, by WHO region and World Bank income group.

100 90 80 70 60 50 40 30 % of countries 20 10 0 AFR AMR EMR EUR SEAR WPR ow- ower- Upper- High- Global income middle- middle- income income income

Yes No/Not Yet Don’t know / No response

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

THE IMPACT OF THE COVID-19 PANDEMIC 5 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT In terms of disruption of activities, 77% of countries reported countries. Finally, around one in four low- (27%) and middle- some disruption to ministry of health NCD activities planned income- countries (26%) reported that activities related to for the current year (Figure 6). Besides public screening the implementation of the WHO HEARTS technical package programmes for NCDs, which WHO advised countries to were postponed. Roughly a quarter (26%) of countries indicated suspend during the pandemic, countries were most likely that other ministry of health NCD activities were impacted and to report disruption to the implementation of NCD Surveys were invited to provide a description of these other activities. (39%) and suspension of mass communication campaigns Among these comments, policy and guideline development (37%). The WHO Package for Essential NCDs (PEN) training was most commonly noted (18 countries) followed by trainings and implementation in primary health was disrupted in 65% (11 countries) and conferences (nine countries). of low-income countries and 49% of lower-middle-income

FIGURE 6 Percentage of countries reporting disruptions to ministry of health NCD activities planned for the current year, by WHO region and World Bank income group.

100 90 80 70 60 50 40

% of countries 30 20 10 0 AFR AMR EMR EUR SEAR WPR ow- ower- Upper- High- Global income middle- middle- income income income None Implementation of NCD Surveys Public screening programs for NCDS

WHO Package for Essential NCDs WHO HEARTS technical package Mass communication campaigns (PEN) training and implementation in Primary Health Care

Others

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

NCD-RELATED HEALTH SERVICES

Countries were asked to report on the government policies Access to inpatient NCD services was generally less impacted. pertaining to the access of essential NCD services at Sixty-two per cent (62%) of countries reported that inpatient primary, secondary and tertiary care levels for both inpatient NCD services were open while just over a third (35%) reported and outpatient services during the COVID-19 pandemic. that inpatient NCD services were open for emergencies only. Unsurprisingly, there was a clear relationship between the No countries reported that inpatient services were closed. transmission level of COVID-19 and the restrictions on access Overall, 35% of countries reported that both inpatient and to essential NCD services (Figure 7). Fifty-nine per cent outpatient services were open, 29% had restricted access (59%) of countries reported that access to outpatient services to both and 25% had restricted access to only outpatient were restricted to some degree, including 4% reporting total services. Seven countries (4%) closed outpatient services yet closure. Thirty-eight per cent (38%) of countries reported that maintained inpatient services, either generally (three countries) NCD outpatient services remained open with no restrictions or for emergencies only (four countries). on access.

6 FIGURE 7 Percentage of countries reporting government policies restricting access to outpatient and inpatient NCD services, by COVID-19 transmission status a. Outpatient NCD services

100 90 80 70 60 50 40

% of countries 30 20 10 0 No cases Sporadic Clusters Community Global

Outpatient NCD services are open Outpatient NCD services are open Outpatient NCD services with limited acccess and/or staff are closed Don’t know / No response or in alternate locations or with different modes b. Inpatient NCD services 100 90 80 70 60 50 40

% of countries 30 20 10 0 No cases Sporadic Clusters Community Global

Inpatient NCD management Inpatient NCD management services Don’t know / No response services are open are open for emergencies only

In addition to reporting government policies on access to Around half of countries reported complete or partial inpatient and outpatient services, countries reported more disruptions to hypertension management services (53%) or specifically on disruptions to a number of NCD-related diabetes and diabetic complication management services services. Three-quarters (75%) of countries reported that (49%), with lower-middle-income countries being somewhat there was some disruption to one or more of the eight services more likely to report disruptions to these services than listed in the questionnaire (Figure 8). Globally, rehabilitation countries in all other income groups. Asthma services (48%), services were the most likely to be impacted, with 50% of palliative care services (48%) and urgent dental care (45%) countries reporting partial disruption and an additional 12% were also widely reported as disrupted. Although cancer reporting complete disruption. Rehabilitation services were treatment services (42%) and services for cardiovascular particularly impacted in the African and European regions emergencies (31%) were less widely reported as disrupted, the with 71% and 79% of countries reporting disruptions in each global figures mask marked differences across income groups. region, respectively. While half (50%) of low-income countries reported disruptions to services for cardiovascular emergencies, only 17% of high-

THE IMPACT OF THE COVID-19 PANDEMIC 7 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT income countries reported any disruptions. Likewise, 58% of disruptions to service. On the contrary, well over half (58%) low-income countries reported disruptions to cancer treatment of countries reporting that both their outpatient and inpatient services compared to 26% of high-income countries. services were open reported disruptions to one or more of the NCD-related services. It is important to note that maintaining access to inpatient and outpatient services does not imply that there are no

FIGURE 8 Percentage of countries reporting disruptions to NCD-related services. 100 90 80 70 60 50 40

% of countries 30 20 10 0 Rehabilitation Hypertension Diabetes and Asthma Palliative care Urgent Cancer Cardiovascular services management diabetic services services dental care treatment emergencies complications management

Partially disrupted Completely disrupted

Countries reporting any disruption to NCD-related services and lockdowns hindering access to the health facilities for were requested to indicate the main causes of the disruption. patients was also reported by over 40% of countries. Around The questionnaire posed 11 possible causes plus a field to one in three countries reported that impacts on staffing, write-in additional causes with countries able to select all closure of outpatient disease-specific clinics and insufficient options that were applicable. A decrease in inpatient volume PPE were one of the main causes of disruption to NCD-related due to cancellation of elective care was the most commonly services. Approximately one quarter of countries reported that reported cause (Table 2). These cancellations were not government-mandated closure of outpatient NCD services, a necessarily due to government policies reducing inpatient decrease in outpatient volume due to patients not presenting services to emergencies, however, as just over half of these or a lack of inpatient services/hospital beds were among countries had reported in the previous question that access the main causes of disruption. Finally, one in five countries to inpatient services had been restricted through government reported that unavailability/stock outs of essential medicines or policies. Closure of population-level screening programmes technologies were causing disruptions to NCD-related services.

TABLE 2 Main causes of disruption to NCD-related services Disruption cause (by decreasing prevalence) % of countries (out of 122 reporting disruptions) Decrease in inpatient volume due to cancellation of elective care 65 Closure of population-level screening programmes 46 Government or public transport lockdowns hindering access to the health facilities for patients 43

NCD related clinical staff deployed to provide COVID-19 relief 39 Closure of outpatient disease specific consultation clinics 34

Insufficient Personal Protective Equipment (PPE) available for health care providers to provide services 33 Insufficient staff to provide services 32 Closure of outpatient NCD services as per government directive 26 Decrease in outpatient volume due to patients not presenting 25 Inpatient services/hospital beds not available 25 Unavailability/Stock out of essential medicines, medical diagnostics or other health products at health facilities 20 Others 18

8 The global figures showing the overall prevalence of (Figure 9). Whereas as all other causes showed the opposite various disruptions hide differing patterns by income group. trend, with greater frequency in the wealthier income groups. Some underlying causes, namely disruptions to transport, Only a decrease in inpatient volume due to cancellation of insufficient PPE, insufficient staff, and unavailability/stock elective care was consistently high across all income groups, out of essential medicines and services were far more likely with a slightly greater frequency among upper-middle- and to be reported by low- and lower-middle-income countries high-income countries.

FIGURE 9 Percentage of countries* reporting main causes of disruption to NCD-related services.

100 90 80 70 60 50 40 30 20 10

% of countries reporting disurptions 0 ow-income ower-middle- Upper-middle- High-income Global income income

Government or public Insuﬃcient Personal Protective Insuﬃcient staff transport lockdowns Equipment (PPE) available for health to provide services care providers to provide services Unavailibity/Stock out of essential Closure of outpatient NCD services Decrease in outpatient volume medicines, medical diagnostics or other as per government directive due to patients not presenting health products at health facilities

Inpatient services/hospital beds Closure of outpatient disease speciﬁc NCD related clinical staff not available consultation clinics deployed to provide COVID-19 relief Decrease in inpatient volume due to cancellation of elective care

* Out of 122 countries reporting disruptions to NCD-related services

Countries most commonly reported that they used triaging to of telemedicine as the income level increased, although even identify priorities to overcome the disruptions to NCD-related among low-income countries 42% of those with service services, with 64% of countries with any disruptions reporting disruptions reported utilizing this technology. Redirection of use of this technique to overcome disruptions (Figure 10). patients with NCDs to alternate health care facilities, novel Triaging was widely used across all regions with the notable supply chain and/or dispensing approaches for NCD medicines exception of the South-East Asia Region, where just a single and task shifting/role delegation were each reported as one country reported utilizing this strategy. Telemedicine was of the means to overcome service disruptions in 40-46% of also very widely used to overcome service disruptions, with countries with service disruptions. 61% of countries with any service disruptions reporting use of this technology. There was a trend of increasing utilization

THE IMPACT OF THE COVID-19 PANDEMIC 9 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT FIGURE 10 Percentage of countries* reporting utilization of methods to overcome disruption to NCD-related services, by WHO region and World Bank income group.

100 90 80 70 60 50 40 30 20 10

% of countries reporting disurptions 0 AFR AMR EMR EUR SEAR WPR ow- ower- Upper- High- Global income middle- middle- income income income

Triaging to identify priorities Telemedicine deployment Redirection of patients with to replace in-person consults NCDs to alternate health care facilities

Novel supply chain and/or dispensing Task shifting/role delegation Others approaches for NCD medicines

* Out of 122 countries reporting disruptions to NCD-related services

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

SURVEILLANCE

Three-quarters (75%) of countries reported the ministry responded affirmatively. Responses were also affirmative of health was collecting or collating data on NCD-related across all income groups, although there was a greater comorbidities in COVID-19 patients (Figure 11). The majority likelihood of collecting or collating NCD-related comorbidities of countries in all regions except the South-East Asia Region with increasing country wealth.

FIGURE 11 Percentage of countries collecting or collating data on NCD-related comorbidities in COVID-19 patients. 100 90 80 70 60 50 40 30 % of countries 20 10 0 AFR AMR EMR EUR SEAR WPR ow- ower- Upper- High- No Sporadic Clusters Community Global income middle- middle- income cases income income

Yes No Not applicable Don’t know

AFR: WHO African Region; AMR: WHO Region of the Americas; EMR: WHO Eastern Mediterranean Region; EUR: WHO European Region; SEAR: WHO South-East Asia Region; WPR: WHO Western Pacific Region.

10 SUGGESTIONS FOR TECHNICAL SUPPORT

Countries were invited to provide suggestions of tools or patient or health care provider safety, as well as guidelines technical guidance WHO could develop related to NCDs for possible drug interactions between patients’ current during the COVID-19 outbreak. This question was open- NCD-related medication and those to treat the virus. About ended, and responses were numerous and varied, but a few a dozen countries specifically asked for guidance on utilizing patterns emerged from the data. Most commonly requested telemedicine or mHealth technologies to provide care and was guidance on continuing NCD prevention and control support for NCD patients and a similar number requested programmes during the pandemic, such as how to ensure support on developing communication materials addressing continuity of essential NCD services without jeopardizing NCDs and their risk factors in the context of the pandemic.

DISCUSSION

This study provided detailed information on the impact disruption in detail reveal that a halt of admissions to inpatient of the COVID-19 pandemic on health services for NCDs. and outpatient rehabilitation services and early discharge and Three-quarters (75%) of countries reported a considerable reduction of activities not only has a huge individual impact degree of disruption of NCD services with urgent dental care, on people with NCDs, but also a health system impact, as rehabilitation and palliative care services being most likely to the level of rehabilitation demand after the crisis is expected be completely disrupted. This was seen to be consistent across to increase substantially (8). all regions and income groups. The most common reasons for The main reason for disruption of services outlined by service disruptions were cancellation of elective care, lack of countries was the decrease in inpatient volume due to transport due to imposed lockdowns, insufficient staff and the cancellation of elective care. These cancellations were closure of hospital services. The information obtained through observed in the majority of countries but were not necessarily this study provides very important insight on how countries due to government policies reducing inpatient services to need to be supported during the response to COVID-19, and emergencies. Many of the countries which indicated such how to plan to build back better health systems with integrated cancellations also indicated that access to inpatient services NCD services after the pandemic. had not been restricted through government policies. A study With the rapid spread of COVID-19 across the world, showed some of the devastating consequences of such the ability of countries to address and respond to NCDs has cancellations as 28 million elective surgeries worldwide will been impacted. Evidence so far shows a clear link between be cancelled or postponed in 2020 worldwide (12). Globally, NCDs and Covid-19, as people with pre-existing NCDs 2.3 million cancer surgeries have been cancelled or postponed appear to be more vulnerable to becoming severely ill or even as well as 6.3 million orthopaedic operations during the dying from the virus (10). The study findings show that in peak 12-week period of Covid-19. Another major reason the majority of countries essential services for hypertension for disruption of services is the closure of population-level management, diabetes or cancer have been disrupted, screening programmes and lockdowns hindering access to drawing attention to countries’ NCD burden and leaving the health facilities for patients. Furthermore, around one in millions of people unattended. This disruption, coupled with three countries also reported that impacts on staffing, closure the increased exposure to numerous behavioral risk factors of outpatient disease-specific clinics and insufficient PPE were for NCDs such as unhealthy diet, alcohol use, lack of physical among the main causes of disruption to NCD-related services. activity and stress, driven by the control measures adopted by The present survey revealed that the underlying causes for many countries, has put people with NCDs in a disadvantaged existing disruptions in NCD services vary across income groups, position. In addition, the fear of contagion people with NCDs with disruptions to transport, insufficient PPE, insufficient experience decreases the likelihood of these people seeking staff, unavailability/stock out of essential medicines and medical care, leading to worse health outcomes (11). services impacting low- and lower-middle-income countries to The disruption of health services, however, is particularly a greater degree. Similarly, a report by the International Labor problematic for those living with NCDs who need regular or Organization also noted that in many low-income countries long-term care. Our findings show that rehabilitation care is large parts of the population do not have access to essential among the most commonly disrupted services. In the African health services during the crisis due to the lack of health and European regions, rehabilitation care has been disrupted in workers, particularly in rural and remote areas (13). 71% and 79% of countries, respectively. Studies exploring this

THE IMPACT OF THE COVID-19 PANDEMIC 11 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT Encouragingly, the study findings show that countries have response plans that do not address NCDs, and to work with adopted alternative strategies to ensure people at highest countries to ensure NCDs are not omitted from pandemic risk continue to receive treatment for NCDs. The most widely and emergency response plans in the future. That only 17% of used strategy, implemented in over two-thirds of countries, countries reported that there was additional funding allocated has been triaging. Triaging was reported more frequently by for NCDs in the government budget for the COVID-19 upper-middle and high-income countries, probably indicating response is also alarming. This is despite abundant evidence that these countries already had a system of triaging which showing that people with NCDs are more vulnerable to could be resorted to rapidly when the need arose; whereas becoming seriously ill with the Covid-19 virus, and that in low and lower-middle-income countries triaging was not as they require access to treatment to manage their illnesses. commonly practiced in routine health services. There have been Therefore, it is very important that health care services for different triage applications and approaches in each country people living with NCDs are included in national response based on government decisions but unfortunately no evidence and preparedness plans for COVID-19. Only through inclusion so far provides a basis for comparison of the effectiveness of people with NCDs in their plans can countries “build back of different models. WHO has published an algorithm for better” and strengthen their health services so that they are COVID-19 patient triage and referral for resource-limited better equipped to prevent, diagnose and provide care for settings during community transmission (14). The document NCDs in the future. outlines how countries can adopt an efficient triage system at Countries used the survey as an opportunity to express their all health facility levels (primary, secondary and tertiary) and need for urgent guidance and support from WHO. More how this will help the national response planning and case specifically, there is a critical need for concrete and practical management system cope with patient influx as well as protect guidance on the continuity of essential health and community the safety of health-care workers. The algorithm is intended services for NCDs. Monitoring the access to and continuity for use by ministries of health, hospital administrators and of essential health services for NCDs would be required. health workers involved in response planning for COVID-19 This opportunity could be utilized to develop systematic and/or patient triage, management and referral. approaches to digital health care solutions. Focusing on The other common mitigation measure adopted by countries COVID-19-related activities and continuing to provide was the increased use of telemedicine (advice by telephone essential services is important not only to maintain people’s or online means). Among the countries reporting service trust in the health system to deliver essential health services disruptions, 58% are now using telemedicine to replace in-person but also to minimize an increase in morbidity and mortality consultations. As expected, since use of telemedicine is from other health conditions. highly dependent on availability of technology and expertise, This study needs to be seen in light of several strengths and it has been used more frequently in high-income countries as limitations. The large number of countries which participated compared to low-income countries. However, the encouraging in the survey provided a wide spectrum of responses from finding was that telemedicine was being utilized by over 40% countries across regions and income groups. The extent of of low-income countries and half of lower-middle-income service disruption and how countries were able to respond countries that participated in the survey. There is still no to these disruptions was of course linked to the stage of published evidence on the mechanisms and response to the pandemic, which was evolving in many countries. These telemedicine approaches used in countries to address results thus reflect the situation as of May 2020. As a key the disruption of NCD services, but such information would informant survey, the survey responses reflect the views of be extremely important to understand how the use of remote the NCD focal point in the ministry of health (or equivalent health care can be improved and reach anyone in need. office) and could not be validated in detail. While the survey Notably, two-thirds of participating countries reported that respondents can report with authority on the current situation, ensuring the continuity of NCD services was included in it is inevitable that in such a rapidly evolving situation responses the list of essential health services in their COVID-19 national are nevertheless limited by the information available at a plans, with low-income countries markedly less likely to given point in time. A broader but similarly structured survey report including NCDs in their COVID-19 response plans than on service disruptions due to COVID-19 was implemented middle- and high-income countries. However, not all countries by WHO in the weeks following the present survey, which submitted these plans along with their response and an initial contained a few overlapping items. A comparison of the results review of COVID-19 plans that have been received suggests of both surveys showed a good degree of consistency but there is significant over-reporting of NCD inclusion in these with the inevitable reductions or improvements in service plans. Further work is thus needed to explore why so many availability depending on the evolution of the pandemic within countries responded positively despite having COVID-19 the responding country. It is also worth noting that many

12 countries were unable to answer certain questions, such as respond independently from the national government, a single the reallocation of government funds for NCDs to COVID-19. response is not sufficiently nuanced. The survey thus provided Additionally, in many large countries where the extent of an overall picture of the probable situation in each country health service disruption may not be the same everywhere from a national perspective. and subnational governments have greater autonomy to

CONCLUSION

This study has highlighted the effect of the COVID-19 their list of essential health services. However, to build back pandemic on NCD services globally. It revealed that three- better health systems during and after the crisis, governments quarters of countries reported a considerable degree of need to commit and ensure that people living with NCDs disruption to NCD services – a finding that has been consistent do not experience disruptions to essential health services. across all regions and income groups. The disruption of Countries need to tackle the impacts of NCDs in their national services has been particularly problematic for those living COVID-19 response and preparedness plans to develop with NCDs who need regular or long-term care. Encouraging strengthened health systems with integrated NCD care for findings of the survey were that alternative strategies like future health emergencies. NCD prevention and management triaging and telemedicine have been adopted by many of is the insurance policy to improve population health and the countries to address the disruptions, and continuity of mitigate the impact of any future crisis. NCD services has been ensured by some of the countries in

REFERENCES

1. Global Health Estimates 2016: deaths by cause, age, sex, by 9. World Health Organization. 2020. Covid-19 situation report. country and by region, 2000–2016. Geneva, World Health Available at: Organization; 2018. https://www.who.int/docs/default-source/coronaviruse/ situation-reports/20200518-covid-19-sitrep-119. 2. Institute for Health Metrics and Evaluation. 2020. GBD results pdf?sfvrsn=4bd9de25_4 tool. Available at: http://ghdx.healthdata.org/gbd-results-tool 10. World Health Organization. 2020. Information note: NCDs 3. World Health Organization, The World Bank. World report on and Covid-19. Geneva, Switzerland disability. Geneva: World Health Organization, 2011. 11. San Lau, L., Samari, G., Moresky, R. T., Casey, S. E., Kachur, 4. Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, S. P., Roberts, L. F., & Zard, M. (2020). COVID-19 in functioning, and disability in older adults-present status and humanitarian settings and lessons learned from past future trends. The Lancet. 2015;385(9967):563-75. epidemics. Nature Medicine, 26(5), 647-648. 5. World Health Organization. 2020 WHO report on cancer. 12. COVIDSurg Collaborative. (2020). Elective surgery Geneva, Switzerland cancellations due to the COVID‐19 pandemic: global 6. Jones, D., Neal, R. D., Duffy, S. R., Scott, S. E., Whitaker, K. L., predictive modelling to inform surgical recovery plans. & Brain, K. (2020). Impact of the COVID-19 pandemic on the British Journal of Surgery. symptomatic diagnosis of cancer: the view from primary care. 13. International Labor Organization. 2020. COVID-19: Are The Lancet. Oncology, 21(6), 748. there enough health workers? Available at: 7. Mafham, M., Spata, E., Goldacre, R., Gair, D., et al. https://ilostat.ilo.org/covid-19-are-there-enough-health- 2020. COVID-19 pandemic and admission rates for and workers/ management of acute coronary syndromes in England. Lancet 14. World Health Organization. (2020). Algorithm for COVID-19 8. Negrini, S., Grablievec, K., Boldrini, P., Kiekens, C., et al. triage and referral: patient triage and referral for resource- 2020. Up to 2.2 million people experiencing disability suffer limited settings during community transmission. collateral damage each day of COVID-19 lockdown in Europe. Eur J Phys Rehabil Med. 56(3): 361-365

THE IMPACT OF THE COVID-19 PANDEMIC 13 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT ANNEXES

RAPID ASSESSMENT OF SERVICE DELIVERY FOR NONCOMMUNICABLE DISEASES DURING THE COVID 19 PANDEMIC

14 ANNEX 1: WHO MEMBER STATES AND SURVEY RESPONDENTS

* signifies a non-responding country

WHO AFRICAN REGION

Algeria* Eswatini Namibia* Angola Ethiopia Niger Benin Gabon Nigeria Botswana Gambia Rwanda Burkina Faso Ghana Sao Tome and Principe Burundi Guinea Senegal Cabo Verde Guinea-Bissau Seychelles Cameroon Kenya Sierra Leone Central African Republic* Lesotho South Africa Chad* Liberia South Sudan Comoros Madagascar Togo Congo Malawi Uganda* Côte d’Ivoire Mali United Republic of Tanzania Democratic Republic of the Congo Mauritania Zambia Equatorial Guinea* Mauritius Zimbabwe Eritrea Mozambique

WHO REGION OF THE AMERICAS

Antigua and Barbuda Dominica Panama Argentina Dominican Republic Paraguay Bahamas* Ecuador Peru Barbados El Salvador* Saint Kitts and Nevis Belize* Grenada Saint Lucia Bolivia (Plurinational State of) Guatemala Saint Vincent and the Grenadines Brazil Guyana Suriname Canada Haiti Trinidad and Tobago Chile Honduras United States of America Colombia* Jamaica Uruguay Costa Rica Mexico* Venezuela (Bolivarian Republic of) Cuba Nicaragua*

WHO EASTERN MEDITERRANEAN REGION

Afghanistan Kuwait Saudi Arabia Bahrain Lebanon Somalia* Djibouti Libya Sudan Egypt* Morocco Syrian Arab Republic Iran (Islamic Republic of) Oman Tunisia Iraq Pakistan* United Arab Emirates Jordan Qatar Yemen

THE IMPACT OF THE COVID-19 PANDEMIC 15 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT WHO EUROPEAN REGION

Albania Greece Portugal* Andorra Hungary* Republic of Moldova Armenia Iceland Romania Austria* Ireland Russian Federation Azerbaijan Israel San Marino* Belarus Italy Serbia* Belgium* Kazakhstan Slovakia Bosnia and Herzegovina Kyrgyzstan Slovenia Bulgaria* Latvia* Spain* Croatia Lithuania Sweden Cyprus Luxembourg* Switzerland Czechia Malta Tajikistan* Denmark Monaco* Turkey Estonia Montenegro* Turkmenistan Finland Netherlands Ukraine France North Macedonia United Kingdom* Georgia Norway Uzbekistan Germany Poland

WHO SOUTH-EAST ASIA REGION

Bangladesh Indonesia Sri Lanka Bhutan Maldives Thailand Democratic People’s Republic of Korea Myanmar Timor-Leste India* Nepal

WHO WESTERN PACIFIC REGION

Australia Malaysia Philippines Brunei Darussalam Marshall Islands* Republic of Korea Cambodia Micronesia (Federated States of) Samoa China Mongolia Singapore Cook Islands Nauru Solomon Islands Fiji New Zealand Tonga Japan Niue Tuvalu Kiribati Palau Vanuatu Lao People’s Democratic Republic Papua New Guinea Viet Nam

16 ANNEX 2: LIST OF COUNTRIES BY WORLD BANK INCOME GROUP

Categories for this report were based on the income categories published in July 2019

HIGH INCOME

Andorra Greece Poland Antigua and Barbuda Hungary Portugal Australia Iceland Qatar Austria Ireland Republic of Korea Bahamas Israel Saint Kitts and Nevis Bahrain Italy San Marino Barbados Japan Saudi Arabia Belgium Kuwait Seychelles Brunei Darussalam Latvia Singapore Canada Lithuania Slovakia Chile Luxembourg Slovenia Croatia Malta Spain Cyprus Monaco Sweden Czechia Netherlands Switzerland Denmark New Zealand Trinidad and Tobago Estonia Norway United Arab Emirates Finland Oman United Kingdom France Palau United States of America Germany Panama Uruguay

UPPER-MIDDLE INCOME

Albania Fiji Nauru Algeria Gabon Niue Argentina Georgia North Macedonia Armenia Grenada Paraguay Azerbaijan Guatemala Peru Belarus Guyana Romania Belize Iran (Islamic Republic of) Russian Federation Bosnia and Herzegovina Iraq Saint Lucia Botswana Jamaica Saint Vincent and the Grenadines Brazil Jordan Samoa Bulgaria Kazakhstan Serbia China Lebanon South Africa Colombia Libya Sri Lanka Cook Islands Malaysia Suriname Costa Rica Maldives Thailand Cuba Marshall Islands Tonga Dominica Mauritius Turkey Dominican Republic Mexico Turkmenistan Ecuador Montenegro Tuvalu Equatorial Guinea Namibia Venezuela (Bolivarian Republic of)

THE IMPACT OF THE COVID-19 PANDEMIC 17 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT LOWER-MIDDLE INCOME

Angola India Philippines Bangladesh Indonesia Republic of Moldova Bhutan Kenya Sao Tome and Principe Bolivia (Plurinational State of) Kiribati Senegal Cabo Verde Kyrgyzstan Solomon Islands Cambodia Lao People’s Democratic Republic Sudan Cameroon Lesotho Timor-Leste Comoros Mauritania Tunisia Congo Micronesia (Federated States of) Ukraine Côte d’Ivoire Mongolia Uzbekistan Djibouti Morocco Vanuatu Egypt Myanmar Viet Nam El Salvador Nicaragua Zambia Eswatini Nigeria Zimbabwe Ghana Pakistan Honduras Papua New Guinea

LOW INCOME

Afghanistan Guinea Sierra Leone Benin Guinea-Bissau Somalia Burkina Faso Haiti South Sudan Burundi Liberia Syrian Arab Republic Central African Republic Madagascar Tajikistan Chad Malawi Togo Democratic People’s Republic of Korea Mali Uganda Democratic Republic of the Congo Mozambique United Republic of Tanzania Eritrea Nepal Yemen Ethiopia Niger Gambia Rwanda

18 ANNEX 3:QUESTIONNAIRE

INTRODUCTORY STATEMENT

Dear colleague,

In recent months, you or other colleagues in your team may out to you to seek any clarifications if needed. Should have kindly participated in the NCD (Noncommunicable we decide later to use examples or case studies that Disease) Country Capacity Survey. In the context of identify specific countries, we will contact you to request COVID-19 Pandemic response, we are reaching out to you advance permission. to ask a small set of additional questions as a follow up to Since these questions are intended to support a rapid this survey to quickly assess how NCD essential services are situation assessment on these issues, we would be grateful being impacted in your country by the current pandemic, to receive your responses by 15 May 2020. Please click on to help plan WHO support and technical tools which might the link below to access the survey. Note that you may access be of value. We greatly appreciate your time and effort to the questionnaire as many times as needed, saving your respond to these questions. responses as you go.

Survey responses will be treated confidentially, and only Thank you in advance. aggregated results will be used for reporting. We may reach

INFORMATION ON THOSE WHO COMPLETED THE QUESTIONS

Who is the focal point who provided the responses?

Name:

Position:

Organization:

Country:

Email Address:

THE IMPACT OF THE COVID-19 PANDEMIC 19 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT INFRASTRUCTURE

1. Are the Ministry of Health (or equivalent institutes) 2. How much of the government (or Ministry of Health) funds staff with responsibility for NCDs and their risk factors initially allocated for NCDs have been reassigned being reassigned/deployed to help with overall to non-NCD services due to COVID-19 response efforts? COVID-19 response? ❍ None or not yet ❍ 1-25% ❍ 26 -50% ❍ Yes - All staff supporting COVID-19 efforts full time ❍ 51-75% ❍ 76 -100% ❍ Don’t know ❍ Yes - All staff partially supporting COVID-19 efforts along with routine NCD activities ❍ Yes - Some staff supporting COVID-19 efforts full time ❍ Yes - Some staff partially supporting COVID-19 efforts along with routine NCD activities ❍ No ❍ Don’t know

POLICIES AND PLANS

3. Is ensuring continuity of NCD services included in the list 5. Is there additional funding allocated for NCDs of essential health services in your country’s COVID-19 in the government budget for the COVID-19 response? response plan? ❍ Yes ❍ No ❍ Don’t know IF RESPONSE IS “No/Not Yet” or “Don’t Know”, SKIP TO QUESTION 5.

❍ Yes ❍ No / Not Yet ❍ Don’t know 6. Which of the following Ministry of Health NCD activities (Kindly upload your country’s COVID-19 response plan if planned for this year have been postponed because of available) COVID-19? (check all that apply)

❍ None 4. Which NCD services are included in the list ❍ Implementation of NCD Surveys of essential health services of your country’s COVID-19 ❍ Public screening programs for NCDS response plan? ❍ WHO Package for Essential NCDs (PEN) training and implementation in Primary Health Care a. Cardiovascular diseases services ❍ Yes ❍ No ❍ WHO HEARTS technical package ❍ Mass communication campaigns b. Cancer services ❍ Yes ❍ No ❍ Others (please specify what other NCD activity/activities c. Diabetes services ❍ Yes ❍ No have been postponed due to COVID-19)

d. Chronic respiratory disease services ❍ Yes ❍ No

e. Chronic kidney disease and dialysis services ❍ Yes ❍ No

f. Dental services ❍ Yes ❍ No

g. Rehabilitation services ❍ Yes ❍ No

h. Tobacco cessation services ❍ Yes ❍ No

i. Others (please specify other NCD services included in the list of essential services)......

20 NCD-RELATED HEALTH SERVICES

7. During the COVID-19 pandemic, what are the government 9. What are the main causes of this disruption(s)? policies for access to essential NCD services at primary, (check all that apply) secondary and tertiary care levels? (please answer for both ❍ Closure of outpatient NCD services outpatient and inpatient services) as per government directive a. ❍ Outpatient NCD services are open ❍ Closure of outpatient disease specific consultation clinics ❍ Outpatient NCD services are open with limited access ❍ Closure of population level screening programs and/or staff or in alternate locations or with different modes ❍ Decrease in outpatient volume ❍ Outpatient NCD services are closed due to patients not presenting ❍ Don’t know ❍ Decrease in inpatient volume due to cancellation of elective care b. ❍ Inpatient NCD management services are open ❍ Inpatient services/hospital beds not available ❍ Inpatient NCD management services are open ❍ Insufficient staff to provide services for emergencies only ❍ NCD related clinical staff deployed to provide COVID-19 ❍ Inpatient NCD management services are closed relief ❍ Don’t know ❍ Insufficient Personal Protective Equipment (PPE) available for health care providers to provide services ❍ Unavailability/Stock out of essential medicines, medical 8. Which of the following NCD-related services have been diagnostics or other health products at health facilities disrupted due to COVID-19? ❍ Government or public transport lockdowns hindering IF RESPONSE TO ALL SUBQUESTIONS IS “Not access to the health facilities for patients disrupted” OR “Don’t know”, SKIP TO QUESTION 12 ❍ Others (please specify what are the other causes of this a. Hypertension Management disruption): ...... ❍ Completely disrupted ❍ Partially disrupted ...... ❍ Not disrupted ❍ Don’t know b. Cardiovascular emergencies (including MI, Stroke and cardiac Arrhythmias) 10. What approaches are being used to overcome ❍ Completely disrupted ❍ Partially disrupted the service disruptions to NCD management and prevention ❍ Not disrupted ❍ Don’t know in public sector health facilities? (check all that apply) c. Cancer Treatment ❍ Telemedicine deployment to replace in-person consults ❍ ❍ Completely disrupted Partially disrupted ❍ Task shifting/role delegation ❍ ❍ Not disrupted Don’t know ❍ Novel supply chain and/or dispensing approaches for d. Diabetes and Diabetic Complications Management NCD medicines (e.g. anti-hypertensives, insulin, painkillers, ❍ Completely disrupted ❍ Partially disrupted antibiotics) through other channels ❍ Not disrupted ❍ Don’t know ❍ Triaging to identify priorities ❍ Redirection of patients with NCDs to alternate health care e. Asthma services facilities ❍ Completely disrupted ❍ Partially disrupted ❍ Others (please describe what other approaches are being ❍ Not disrupted ❍ Don’t know used):...... f. Urgent dental care ...... ❍ Completely disrupted ❍ Partially disrupted ❍ Not disrupted ❍ Don’t know 11. What are your country’s plans to re-initiate any suspended NCD services? g. Rehabilitation services ❍ ❍ Completely disrupted Partially disrupted ...... ❍ Not disrupted ❍ Don’t know ...... h. Palliative care services ...... ❍ Completely disrupted ❍ Partially disrupted ❍ Not disrupted ❍ Don’t know

THE IMPACT OF THE COVID-19 PANDEMIC 21 ON NONCOMMUNICABLE DISEASE RESOURCES AND SERVICES: RESULTS OF A RAPID ASSESSMENT SURVEILLANCE

12. Is the Ministry of Health collecting or collating data on NCD-related comorbidities in COVID-19 patients?

❍ Yes ❍ No ❍ Don’t know ❍ Not applicable

OTHER SUGGESTIONS

13. Are there any technical guidance or tools that you would suggest WHO to develop related to NCDs during COVID-19 outbreak?

Please use the text box to give your suggestions

Please add any comments on the questions above ......

Thank you for taking time to give your input for this survey. If you have any queries or questions regarding this survey, please reach out to us at [email protected]

TERMS

1. Reassigned/deployed: Temporarily assigned to another unit or team 2. Level of disruption of services • Completely disrupted (more than 50% of in-patients not treated as usual) • Partially disrupted (5% to 50% of in-patients not treated as usual) • Not disrupted (less than 5% of in-patients not treated as usual)

24 ISBN 978-92-4-001029-1